Access to Care for Children with Special Health Care Needs: The Role of Medicaid Managed Care Contracts

States are increasingly enrolling children with special health care needs (CSHCN) into Medicaid managed care delivery systems. Ensuring access to care is especially important for CSHCN because they have health, developmental, and behavioral needs that exceed those of the general pediatric population. To better understand states’ Medicaid managed care access to care requirements for this population of children, MACPAC engaged the Urban Institute and its subcontractor, Health Management Associates, to examine state contracts with Medicaid managed care organizations.

This report presents findings from this analysis, supplemented by interviews with state Medicaid officials, managed care organization representatives, consumer advocates, and other stakeholders. Key findings include:

There is no clear consensus among stakeholders on whether CSHCN-specific access to care contract provisions are necessary or if provisions that apply to all enrollees afford sufficient protections.

The majority of state MCO contracts do not specifically address CSHCN with respect to building provider networks, establishing access standards, or monitoring access to care; instead addressing the general population of enrollees or all enrollees with special health care needs.

The most common contract areas specifically addressing CSHCN are identification, coordination across agencies and programs serving them, and inclusion of pediatric providers in networks.

The findings, statements, and views expressed in this report are those of the authors and do not necessarily reflect those of MACPAC.

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About MACPAC

MACPAC serves as an independent source of information on Medicaid and CHIP issues that include payment, eligibility, enrollment, coverage, access to and quality of care, and the programs' interaction with Medicare and the health system generally. MACPAC’s authorizing statute requires it to submit two reports to Congress annually. The Commission holds public meetings and consults with state officials, congressional and executive branch staff, beneficiaries, health care providers, researchers, and policy experts to carry out its work.